EM@3AM: Post-Tonsillectomy Complications

Author: Brit Long, MD (@long_brit, EM Attending Physician, San Antonio, TX) // Edited by: Alex Koyfman, MD (@EMHighAK)

Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

An 8-year-old male presents 7 days post-tonsillectomy with his mother. She says the patient started spitting up blood this morning. The patient appears well, but suddenly starts throwing up coffee ground emesis. When the patient stops throwing up, you look at the back of the throat and see what appears to be a clot resembling a blackberry.

Triage vital signs (VS): BP 90/55, HR 132, RR 26, SpO2 96% on RA.

What is the patient’s diagnosis? What’s the next step in your evaluation and treatment?

Answer: Post-tonsillectomy complication, specifically bleeding

Background: Tonsillectomy is a common procedure, primarily performed in childhood for several reasons:

• Sleep disordered breathing/apnea
• Severe, recurrent sore throats
• Others include dental issues, hemorrhagic tonsillitis, PTA

Procedure:

• Tonsillectomy: en bloc excision of palatine tonsil and capsule, may have large wound exposed with exposed muscle and blood vessels (more common) OR
• Tonsillotomy: removal of exophytic portion of tonsil, may be associated with less bleeding and pain

Patient Course:

• Procedure is traumatic, resulting in significant edema of the tonsillar pillars and uvula
• A fibrin clot develops on the tonsillar fossae in 24 hours
• Fibrin clot has proliferated significantly by day 5
• Mucosa grows inward from the periphery, followed by the clot separating from tissue around 1 week, which is when the risk of bleeding is highest
• Full healing takes 2 weeks (may be longer)

Evaluation

• History: Date of surgery, previous surgeries, difficulties in surgery, bleeding, PO intake, fevers, neck stiffness, activity, urine output, vomiting, difficulty breathing
  • Specifics you should focus on and ENT will want to know: Coffee ground emesis? Cooperation level and age of patient? How many episodes of bleeding (more than one suggests coagulopathy)? Visible clot? Food and water intake? Hydration status?
• Examination: Assess vital signs, and pay attention to tachycardia, which is typically the first sign of hemodynamic instability in pediatric patients. Assess hydration status, capillary refill, neck, lungs, heart. Carefully perform the ENT and airway exam, with close attention to the pharyngeal structures and the fibrin clot.
• The appearance of the fibrin clot is dependent on time from surgery. Normal appearance is a thick gray coat by day 5. A visible clot (or a “blackberry”) is at high risk of rupture.

Complications

• Complications include pain, postoperative nausea and vomiting, decreased oral intake, airway obstruction, fever/infection, and postoperative bleeding.
• Pain: Sore throat and otalgia are common after the procedure and improve within 2 weeks.
  • Patients will often complain of odynophagia and dysphagia due to pharyngeal muscle trauma.
  • Up to 50% of patients will have severe pain during the first 48 hours after surgery.
  • Codeine-containing medications are not recommended for pain management. Rather, acetaminophen and NSAIDs are the go-to agents.
  • If needed, intranasal ketamine or fentanyl can provide fast pain relief in the ED. Ensure patients are regularly taking acetaminophen and an NSAID.
• Nausea/vomiting: Common after tonsillectomy
  • Affects up to 89% of patients postoperatively. Patients are often provided dexamethasone in surgery to assist with nausea and postoperative edema.
  • Nausea and vomiting worsen dehydration.
  • Provide antiemetics if nausea/vomiting present and assess hydration status.
• Decreased intake and dehydration
  • Due to odynophagia and dysphagia, decreased oral intake is very common. Parents must encourage patients to eat and drink as tolerated.
  • Evaluate hydration status, vital signs, and capillary refill. Patients may be given oral fluids/popsicles for mild/moderate dehydration. If severely dehydrated, provide IV fluids, obtain labs (electrolyte, renal function).
  • Patients with severe dehydration and/or limited oral intake should be admitted.
  • Post-procedure hyponatremia may occur, thought to be due to dehydration-induced ADH secretion, increased hypotonic fluid administration, and decreased oral intake.
  • Timing analgesics and oral intake is key. Cool to cold foods and drinks may help patients tolerate oral intake.
• Airway obstruction:
  • Blood/clots accumulating in the oropharynx may occur acutely, though uncommon. Dislodged tonsillar tissue not fully removed during the procedure can also result in airway obstruction, though this is rare.
    • Patients should be allowed to maintain a position of comfort, and definitive airway may be required. Sedation (with ketamine) as a part of delayed sequence intubation may allow preoxygenation and an attempt to remove the foreign tissue.
  • Patients treated for obstructive sleep apnea are at increased risk of airway obstruction after the procedure. Negative pressure pulmonary edema can occur due to prolonged obstruction of the upper airway and increased intrathoracic pressure. Sudden removal of the tonsils causes increased venous return and pulmonary volume and hydrostatic pressure, pushing fluid in the pulmonary tissue.
    • This is treated with positive pressure ventilation, though definitive airway may be required.
•  Fever/Infection:
  • Patients may be provided postoperative antibiotics, but literature suggests no reduction in infection rates or postoperative pain with these agents.
  • Fever can occur 18-36 hours after tonsillectomy due to atelectasis. However, fever lasting over 24 hours suggests infection, especially when severe odynophagia and throat pain are present.
  • Patients present with severe pain, erythema, difficulty with neck range of motion, and fever over 24 hours must be evaluated for suppurative lymphadenitis or postoperative infection. Though these are rare complications, emergent treatment is necessary with IV antibiotics and ENT consultation. Imaging of the neck is typically recommended as well, starting with soft tissue radiographs. CT with IV contrast may be needed for definitive diagnosis.
•  Post-Tonsillectomy Bleed: Most bleeds stop before the patient arrives in the ED or can be controlled in the ED.
  • Occurs in 0.5-10% of patients undergoing tonsillectomy. Most common in the 21-30 year age group; less common in those < 6 years.
  • Mortality rate approaches 2 for every 10,000 tonsillectomies, with most occurring in the first 24 hours (early/primary bleed).
  • Bleeding occurs in two phases: early and late
  • Early/primary: Bleeding within the first day post-tonsillectomy; accounts for approximately 10% of all bleeds.
    • Commonly due to a surgical technique issue or coagulopathy
    • These patients need emergent ENT consultation and should be managed in the OR
  • Late/secondary: Bleeding around 5-10 days after surgery, accounts for 90% of bleeds (fibrin clot sloughs off in this period)
  • Significant bleeding: Patients with active bleeding or a visible clot (blackberry appearance)
  • Management: Most patients will not be bleeding at time of evaluation, but will have a history of bleeding; a quarter will have minor oozing; 5% are bleeding actively
    • Have patient lean forward/assume position of comfort
    • Discuss patients with ENT, emergently for active bleeding or clot
    • Obtain personal protective equipment, headlamp, Magill forceps, gauze, suction, airway equipment
    • Obtain IV access, bilaterally if able, for severe bleeding
    • Have patient rinse with cold water, lidocaine with epinephrine, and/or TXA. Oxymetazoline and neo-synephrine can also be used.
    • Provide local anesthesia with lidocaine or benzocaine
    • Do NOT remove a clot
    • Local, minor oozing can often be controlled with silver nitrate after analgesia and lidocaine/epi/TXA
    • For more severe bleeding, apply direct pressure to site with Magill’s (wrapped with Kerlix gauze) saturated with epinephrine
    • Place pressure laterally, not posteriorly
    • Ketamine may be required for sedation
    • May require figure-of-eight stitch
    • Send CBC, type and cross, coagulation panel/TEG
    • Consider TXA 15 mg/kg IV and DDAVP 0.3 micrograms/kg IV (for potential undiagnosed coagulopathy)
    • Patients may require blood product transfusion, especially younger patients with low reserve.
    • Continued bleeding despite pressure may warrant intubation and oral packing.
  • Disposition: If minor late/secondary bleeding that has been controlled or no visible clot, discuss with ENT, obtain follow up, and discharge. All patients with early/primary, significant bleeding, or visible clot should be taken to the OR.

Further Reading: